research article open access evidence based post …a mapping of the best evidence underlying the...

RESEARCH ARTICLE Open Access

Evidence based post graduate training.A systematic review of reviews based onthe WFME quality frameworkAnnelies Damen1*, Roy Remmen1, Johan Wens1 and Dominique Paulus2

Abstract

Background: A framework for high quality in post graduate training has been defined by the World Federation ofMedical Education (WFME). The objective of this paper is to perform a systematic review of reviews to find currentevidence regarding aspects of quality of post graduate training and to organise the results following the 9 areas ofthe WFME framework.

Methods: The systematic literature review was conducted in 2009 in Medline Ovid, EMBASE, ERIC and RDRBdatabases from 1995 onward. The reviews were selected by two independent researchers and a quality appraisalwas based on the SIGN tool.

Results: 31 reviews met inclusion criteria. The majority of the reviews provided information about the trainingprocess (WFME area 2), the assessment of trainees (WFME area 3) and the trainees (WFME area 4). One reviewcovered the area 8 ‘governance and administration’. No review was found in relation to the mission and outcomes,the evaluation of the training process and the continuous renewal (respectively areas 1, 7 and 9 of the WFMEframework).

Conclusions: The majority of the reviews provided information about the training process, the assessment oftrainees and the trainees. Indicators used for quality assessment purposes of post graduate training should bebased on this evidence but further research is needed for some areas in particular to assess the quality of thetraining process.

BackgroundThe debate on quality improvement in post graduatemedical education (PME) is ongoing in many countries[1]. In the UK, the Post graduate Medical Education andTraining Board (PMETB) developed generic qualitystandards of training in September 2009 [2]. In the U.S.,the Accreditation Council for Graduate Medical Educa-tion (ACGME) is a private professional organisation andnowadays responsible for the accreditation of more than8500 residency and fellowship programs [3]. Othercountries, for instance the Netherlands and Canada alsodeveloped quality frameworks in PME [4,5].An international framework for quality of PME has been

proposed by the World Federation of Medical Education

(WFME, a non-governmental organization related to theWorld Health Organization). Global Standards for theundergraduate, post graduate and continuing medical edu-cation were developed by three international task forceswith a broad representation of experts in medical educa-tion from all six WHO/WFME Regions [6]. One of theseframeworks aims to introduce a generic and comprehen-sive approach to quality of PME, providing internationallyaccepted standards and national or even regional recogni-tion of programs [6].In the framework above many quality indicators and

rankings are used for assessing the quality of PME.However they are based on expert consensus and afurther interesting step is to know to what extent theyare supported by the evidence: the concrete question isto know if the quality found for each area has an impacton the training outcomes e.g. physicians’ competenciesand ultimately, quality of care [7]. To date, only few

* Correspondence: [email protected] of Family Medicine, Centre for General Practice, University ofAntwerp, Universiteitsplein 1, 2610 Wilrijk, BelgiumFull list of author information is available at the end of the article

Damen et al. BMC Medical Education 2011, 11:80http://www.biomedcentral.com/1472-6920/11/80

© 2011 Damen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

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studies comprehensively explored the literature of thequality of post graduate medical education [8].A mapping of the best evidence underlying the WFME

framework is an ambitious work. In general, individualstudies are biased by local factors and this limits general-ising the findings. Therefore systematic reviews have animportant role in summarizing and synthesizing evidencein medical education on a wider scale [9]. The objectiveof this review is to identify, appraise the quality andsynthesize the best systematic reviews on post graduatemedical education using the WFME standards as a blue-print (Figure 1).

MethodsDatabasesThe systematic literature search was performed from 1995onwards, using the following data sources: Medline Ovid(April 23, 2009), Embase (Excerpta Medica Database untilJune 9, 2009), ERIC (Education Recources InformationCenter) database until July 30, 2009) and RDRB (Researchand Development Resource Base database until August 1,2009) [10,11]. The review included publications in English,French and Dutch.A complementary manual search was performed in

five core Journals (The Lancet, JAMA, New England

1 MISSION AND OUTCOMES 1.1 statements of mission and outcomes1.2 participation in the formulation of mission and outcomes1.3 professionalism and autonomy1.4 training outcomes

2 TRAINING APPROACHES 2.1 learning approaches2.2 scientific methods2.3 training content

2.4 training structure, composition and duration

2.5 the relationship between training and service2.6 management of training

3 ASSESSMENT OF TRAINEES 3.1 assesment methods

3.2 relationship between assessment and training3.3 feedback to trainees

4 TRAINEES 4.1 admission policy and selection4.2 number of trainees4.3 support and counseling of trainees4.4 working conditions4.5 trainee representation

5 STAFFING 5.1 appointment policy

5.2 obligations and development of trainers

6 TRAINING SETTINGS AND EDUCATIONAL RESOURCES 6.1 clinical settings and patients

6.2 physical facilities and equipment6.3 clinical teams6.4 information technology6.5 research6.6 educational expertise6.7 training in other settings and abroad

7 EVALUATION OF TRAINING PROCESS 7.1 mechanism for programme evaluation7.2 feedback from trainers and trainees7.3 using trainee performance

7.4 authorization and monitoring of training settings7.5 involvement of stakeholders

8 GOVERNANCE AND ADMINISTRATION 8.1 governance

8.2 professional leadership8.3 funding and resource allocation8.4 administration8.5 requirements and regulations

9 CONTINUOUS RENEWALFigure 1 WFME areas and sub-areas.


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Journal of Medicine, British Medical Journal, Annals ofInternal Medicine) and five medical education journals(Academic Medicine, Medical Education, BMC MedicalEducation, Medical Teacher, Teaching and Learning inMedicine and Education for Health) from April 1 untilOctober 2009.

Terms usedThe Mesh terms (Medline Ovid)/Emtree terms (Embase)used were “Education, Medical, Graduate or Education”OR “Internship and Residency” OR “Family Practice/ed[Education]” as well as a combinations of terms relatingto the WMFE framework items (quality, standards, legis-lation, education, organization, “organization and admin-istration”, *annual reports as topic, “constitution andbylaws”, governing board, management audit, manage-ment information systems, mandatory programs, organi-zational innovation, program development, public healthadministration, total quality management).In the ERIC database, the search was performed using

the Thesaurus descriptors: “Graduate Medical Education”OR “Family Practice” AND keywords quality OR train*OR staff* OR standards OR organization OR legislation.In the RDRB database, the search was performed using

the key words: graduate medical education OR internshipOR family practice combined with the key words: qualityOR train* OR staff* OR standards OR organization ORlegislation (Table 1).

Selection procedureA total of 3022 unique references were identified. A firstselection of reviews was performed by two independentresearchers (in combinations AD, RR, JW) based on titleand abstract using the following inclusion criteria:

• scope: quality of training programs, training prac-tices, trainers;• description of national, regional or official postgraduate programs;• study design: systematic reviews

Papers were excluded using the exclusion criteria men-tioned in Figure 2. The percentage of agreement betweenassessors was 95.1 percent.Disagreement was resolved in discussion by pairs of

researchers. No arbitrating intervention by a thirdresearcher was needed. Finally, 188 reviews were selectedfor full reading and quality appraisal. One systematicreview found during the manual search completed thelist.

Quality appraisalThe quality appraisal of the selected reviews was per-formed on the full texts by one author (RR or JW) and

was checked by the first author (AD). The researchersused the frameworks of Scottish Intercollegiate NetworkGroup (SIGN) for reviews [12]. The maximal qualityscore was 15. The researchers excluded 3 reviews withlow scores equal to 0 or 1 on three or more items out ofa total of 5 items [13-15]. One review was excludedbecause it used, among other studies in the core curricu-lum, only one study in PME [16].

ResultsAfter the selection procedure, 31 reviews were selectedfor further analysis. Figure 2 overviews the selection pro-cess. Overall, the quality of the 31 reviews (assessed usingthe SIGN criteria) was high (≥ 12/15) in 23 reviews andmoderate (8/15-12/15) in 8 reviews. The selected reviews[17-47] evaluated 1570 primary studies carried out in thecontext of PME. The reviews publication dates rangefrom 2000 to 2009, of which 9 reviews were from January2008 until October 2009.Many reviews did not focus solely on PME. They also

analysed primary studies of undergraduate training oreven the education of other health professionals, forinstance high-fidelity training in undergraduate medicaleducation and continuing medical education [18].Most training settings were not specified (n = 12)

[19-22,27,29,31,33,35,37,45,46]. Some studies mentionedthem i.e. hospital settings (n = 7) [17,18,34,41-44] andoutpatient settings (n = 2) [24,47]. Ten papers studied amixed setting [23,25,26,28,30,32,36,38-40] (i.e. hospitalsetting and/or GP setting and/or outpatient setting and/or not specified).Looking at the first author’s affiliations, the large

majority of studies came from the US (n = 19)[17,18,21,23,24,26,28-31,33,36,37,39,40,42-44,47] and theUK (n = 5) [18,26,31,44,45]. Two first authors resided inCanada [25,41], 2 in Australia [22,35], 1 in the Nether-lands [38], 1 in Spain [20] and 1 in Bahrain [34]. Allpapers were written in English.

Practical messagesAdditional file 1 gives an overview of the selected reviews:the research questions, the number of studies included inthe reviews, the WFME (sub) areas that are covered, theresults and the critical appraisal scores. The followingparagraphs summarise their findings and highlight inter-esting and practical avenues to enhance the quality ofPME. The following paragraphs use the term “trainee” forgeneric areas of PME training. The term “resident” ismore specifically used when this trainee works in a clinicalsetting.WFME areas under studyMost papers studied one particular area of the WFMEframework while three other ones covered more thanone area and/or sub-area [21,24,26]. The majority of the


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Table 1 search strategy (Medline Ovid, Embase, ERIC, RDRB)

1.1)MEDLINE OVID

Keywords 3 MESHS

Education, Medical, Graduate/or Education/

“Internship and Residency"/

Family Practice/ed [Education]

AND

2 Free terms: quality - standards

Date April 23, 2009

Database Medline Ovid

SearchStrategy

1 exp Education, Medical, Graduate/or Education/ 31768

2 exp “Internship and Residency"/ 26607

3 Family Practice/ed [Education] 9044

4 1 or 3 or 2 59921

5 quality.mp. 412313

6 standard.mp. 350030

7 6 or 5 735413

8 train*.mp. 231585

9 8 and 4 and 7 2498

10 limit 9 to ("review articles” and humans and (dutch or english or french) and last 14 years) 131

11 from 10 keep 1-131 131

12 4 and 7 5248

13 limit 12 to ("review articles” and humans and (dutch or english or french) and last 14 years) 216

Note 3 MESHs exploded combined with 2 free terms of interest (quality - standards)

Date April 23, 2009

Database Medline OVID

17 Internship and Residency"/lj, ed, st, og [Legislation & Jurisprudence, Education, Standards, Organization & Administration] 4329

18 Education, Medical, Graduate/lj, ed, st, og [Legislation & Jurisprudence, Education, Standards, Organization & Administration] 3329


20 Family Practice/og, lj, st [Organization & Administration, Legislation & Jurisprudence, Standards] 8460

21 19 and 20 953

22 21 or 18 or 17 7833

23 limit 22 to ("review articles” and humans and yr = “1995-Current” and (dutch or english or french)) 338

Note 3 MESHs focused on the topics of interest: legislation - education - standards - organization

Merge databases: 338 + 216 = 554 papers - 94 duplicates

= 460 papers

Date April 24, 2009

Database Medline Ovid

Dam

enet

al.BMCMedicalEducation

2011,11:80http://w

ww.biom

edcentral.com/1472-6920/11/80

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Table 1 search strategy (Medline Ovid, Embase, ERIC, RDRB) (Continued)

SearchStrategy

1 Exp Education, Medical, Graduate/or Education/ 31769

2 exp “Internship and Residency"/ 26608


4 1 or 3 or 2 59923

21 train*.mp. 231625

33 staff*.mp. 140884

34 *"organization and administration"/or *annual reports as topic/or *"constitution and bylaws"/or governing board/or management audit/or management informationsystems/or mandatory programs/or organizational innovation/or program development/or public health administration/or total quality management/

67323

35 33 or 34 or 21 405544

36 35 and 4 23424

37 limit 36 to ("review articles” and humans and yr = “1995-Current” and (dutch or english or french)) 646

Note 3 MESHs exploded combined with free terms (train* - staff*) and MESHs to reflect the WFME grid

Merge databases: 460 + 646 = 1106 papers - 316 duplicates

= 790 papers

1.2)EMBASE

Keywords 3 Emtree terms

“MEDICAL EDUCATION"/

“EDUCATION"/

“FAMILY PRACTICE”

AND

2 Free terms: quality - standards

Date June 9, 2009

Database Embase

1 ‘medical education’/exp AND [embase]/lim 99195

2 ‘education’/exp AND [embase]/lim 302046

3 ‘general practice’/exp AND [embase]/lim 25131

4 #1 OR #3 OR #2 320689

5 quality AND [embase]/lim 403812

6 standard AND [embase]/lim 329464

7 #5 OR #6 700932

8 train* AND [embase]/lim 206593

9 # 8 AND #4 AND #7 10658

10 #4 AND #7 46774

11 #4 AND #7 AND [review]/lim AND ([dutch]/lim OR [english]/lim OR [french]/lim) AND [embase]/lim AND [1995-2009]/py 7024

12 #4 AND #7 AND ([meta analysis]/lim OR [randomized controlled trial]/lim OR [systematic review]/lim) AND [review]/lim AND ([dutch]/lim OR [english]/lim OR [french]/lim)AND [embase]/lim AND [humans]lim AND [embase]/lim AND [1995-2009]/py

392

Note 3 Emtree terms combined with 2 free terms of interest (quality - standards)

Date

June 9, 2009

Dam

enet


2011,11:80http://w

ww.biom


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13


Database Embase

13 legislation AND [embase]/lim 17350

14 education AND [embase]/lim 315073

15 standards AND [embase]/lim 54455

16 organization AND [embase]/lim 243462

17 #1 AND #13 AND #14 AND #15 AND #16 4

18 #2 AND #13 AND #14 AND #15 AND #16 18

19 #3 AND #13 AND #14 AND #15 AND #16 0

20 #1 AND #13 AND #14 AND #15 AND #16 AND ([metaanalysis]/lim OR [randomized controlled trial]/lim OR[systematic review]/lim) AND [review]/lim AND ([dutch]/lim OR[english]/lim OR [french]/lim) AND [humans]/lim AND [embase]/lim AND [1995-2009]/py

0

21 #13 OR #14 OR #15 OR #16 OR #19 OR #20 588503

22 #1 AND #21 92453

23 #13 OR #15 OR #16 307648

24 #3 AND #23 2303

25 #1 AND #23 10901

26 #2 AND #23 36791

27 #3 AND #24 2303

28 #25 OR #26 OR #27 38427

29 #25 OR #26 OR #27 AND ([meta analysis]/lim OR [ran 95

domized controlled trial]/lim OR [systematic review/lim)

AND [review]/lim AND ([dutch]/lim OR [english]/lim

OR [french]/lim) AND [humans]/lim AND [embase]/lim

AND [1995-2009]/py

Note 3 Emtree terms focused on topics of interest: legislation - education - standards - organization

Date June 9, 2009

Database Embase

SearchStrategy

1 ‘medical education’/exp AND [embase]/lim 99195

2 ‘education’/exp AND [embase]/lim 302046

3 ‘general practice’/exp AND [embase]/lim 25131

5 #1 OR #3 OR #2 320689

6 train* AND [embase]/lim 206655

7 staff* AND [embase]/lim 73410

8 ‘organization and management’/exp AND [embase]/lim 333505

9 ‘health care management’/exp AND [embase]/lim 297404

10 governing AND board AND [embase]/lim 214

11 management AND audit AND [embase]/lim 5795

12 management AND information AND systems AND 7583

[embase]/lim

Dam

enet


2011,11:80http://w

ww.biom


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13


13 mandatory AND programs AND [embase]/lim 626

14 organizational AND innovation AND [embase]/lim 240

15 program AND development AND [embase]/lim 44213

16 public AND health AND administration AND [embase]/lim 14407

17 total AND quality AND management AND [embase]/lim 11402

18 #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 482585

18 #5 OR #6 OR #17 700724

19 #4 OR #18 113868

20 #4 AND #18 AND ([meta analysis]/lim OR [randomized controlled trial]/lim OR [systematic review]/lim) AND [review]/lim AND ([dutch]/lim OR [english]/lim OR [french]/lim)AND [humans]/lim AND [embase]/lim AND [1995-2009]/p

391

Note3 Emtree terms combined with free terms (train* - staff*) and MESHs to reflect the WFME grid

Merge databases: 392 + 95 + 391 = 878 papers - 263 duplicates = 615 papers

1.3) ERIC

Keywords “Graduate Medical Education”

“Family Practice (medicine)”

quality

train*

staff*

standards

organization

legislation

Date July 30, 2009

Database ERIC

SearchStrategy

1) Thesaurus descriptors: “Graduate Medical Education”

OR

2) Thesaurus descriptors: “Family Practice (Medicine)

AND

3) Keywords: quality OR train* OR staff* OR standards OR organization OR legislation

Publication date: 1995-2010

Publication type: journal article

N = 303

1.4) RDRB

Keywords graduate medical education

internship

residenc*

family practice

quality

train*

Dam

enet


2011,11:80http://w

ww.biom


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13


staff*

standards

organization

legislation

Date August 1, 2009

Database RDRB

SearchStrategy

Advanced search

X Search all groups

Key words: graduate medical education OR internship OR family practice

AND

Key words: quality OR train* OR staff*

Limits: 1995-2010

N = 255

Date August 1, 2009

Database RDRB

SearchStrategy

Advanced search

X Search all groups

Key words: graduate medical education OR residenc* OR family practice

AND

Key words: quality OR train* OR staff*

Limits: 1995-2010

N = 234

Merge databases: 255 + 234 = 489 - 234 duplicates

= 255 papers

Date August 1, 2009

Database RDRB

SearchStrategy

Advanced search

X Search all groups

Key words: graduate medical education OR internship OR family practice

AND

Key words: standards OR organization OR legislation

Limits: 1995-2010

N = 293

Merge databases: 255 + 293 = 548 - 89 duplicates

= 459 papers

Dam

enet


2011,11:80http://w

ww.biom


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reviews give detailed information about the training pro-cess (WFME area 2) [17-26], the assessment of trainees(WFME area 3) [21,24,27-33] and the trainees (WFMEarea 4) [26,34-42]. One review covered the ‘governance

and administration’ (WFME area 8) [24]. No reviewfocused on the mission and outcomes, the evaluation ofthe training process and the continuous renewal(respectively areas 1, 7 and 9 of the WFME framework).

Figure 2 Flow chart with selection process of reviews.


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Importance of a core curriculumThe first step for the quality of post graduate medicaltraining is the necessity to describe an effective “core”in-patient curriculum. That was the conclusion of DiFrancesco et al. [17] who analysed the effectiveness ofthe training in internal medicine. They found little dataon the topic and concluded that few data exist to sup-port the quality of this training.Conditions to facilitate learning in PME education:combination of learning approachesIssenberg et al. found that high-fidelity simulations areeducationally effective: they concluded that simulationbased exercises could complement medical education inpatient care settings [18]. High fidelity simulations use rea-listic materials and equipment to represent the task thatthe candidate has to perform. The authors also insist onfour other conditions to facilitate learning i.e. feedback,repetitive practice, opportunities for the trainee to engagein the practice of medical skills across a wide range of dif-ficulties and multiple learning strategies.In the same way another review insists on the feedback

to trainees as a key to success. It should be provided sys-tematically over several years by an authoritative source.Feedback can change clinical performance, but its effectsare influenced by the source and duration of the process[33].Work in team: importance of the clinical settingsWorking as a doctor implies working in teams. One sys-tematic review has listed some principles (cfr additionalfile 1) to enhance the quality of teamwork among futurespecialists [23].Furthermore, it is worthwhile to offer to the future hos-

pital-based specialists adequate exposure to outpatient andambulatory settings as an adjunct to training in inpatientsettings [24]. This exposure leads to better performanceson national Board examinations, Objective StructuredClinical Examinations and tests of clinical reasoning.Another review estimates that residents often lack of con-fidence and competence for common health issuesbecause only 13% of the training takes place in ambulatorycare [47].Growing importance of the portfolio in post graduatemedical trainingA portfolio is a set of materials collected to represent aperson’s work and foster reflective learning. The use of aportfolio gains importance in PME training and authorsalso recommend it as a tool for assessment [21].Selection and assessment of trainees: shortcomings of theacademic resultsThe selection of trainees for PME positions remains a sub-jective exercise: the undergraduate grades and rankingsmoderately correlate with the performance during intern-ship and residency [34]. A selection of trainees based only

on previous academic results in the undergraduate curri-culum poorly predicts the post graduate training.Authors from an Australian study propose a mix of

traits that could predict the success of a future candi-date [35] i.e. communication skills, capacity of adapta-tion to the audience, empathy, understanding of the roleof the nursing and supporting staffs, understanding ofpractice protocol.Assessment of trainees: a call for a global approachMost authors emphasize the need for a global assessmentof the post graduate trainee. Many tools exist e.g. fromthe Objective Structured Clinical Examination [24], theMini-CEX (Mini Clinical Evaluation Exercise = methodof evaluating residents by directly observing a history andphysical examination followed by feedback) [30]. In theUS, the Accreditation Council for Graduate Medical Edu-cation considers the portfolio as a corner stone to evalu-ate the competences. A portfolio must have a creativecomponent that is learner driven [21].Epstein et al. emphasizes the need for a multidimen-

sional assessment based on the observation of trainees inreal situations, on feedbacks of peers and patients and onmeasures of outcomes. The assessment has to targetmany competencies e.g. professionalism, time manage-ment, learning strategies, teamwork [29]. The strongvalidity of evidence has been identified for the Mini-CEXbut the authors conclude that more work is needed toreview the optimal mix and the psychometric characteris-tics of assessment formats in terms of validity and relia-bility [24,30].Working hours and risk of burnout: no optimal answerWorking conditions of trainees are a matter of debate inthe literature. Work hours restrictions may improve thequality of life of the trainees, but it is unclear if theimproved quality of life of residents ultimately results inbetter patient care [26]. Some evidence shows that redu-cing working hours does not impair clinical training, butit may decrease overall continuity of care [48,49]. Itmust be noted that American (80 hour work in theACGME framework) and European directives (a maxi-mum of 48 hours per week since August 2009 [49])greatly differ.Emotional exhaustion and burnout rates in medical

residents are high: authors suggest a prevalence rangingfrom 18% to 82% in medical residents [38]. The perso-nal and professional consequences are potentially dra-matic [39,40] but few interventions are set up to tacklethe problem. Support groups and meditation-type prac-tices have shown promising results but are sometimeshard to replicate [40]. Doctor-nurse substitution has thepotential to reduce doctors workload and direct healthcosts. Trainees welcome these reforms but trainers showreservations [50].


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DiscussionSome evidence in reviews to build a post graduatetraining processThe reviews included in this review show that evidence inthe reviews is available for training processes, assessmentof trainees, and trainee processes. Course organisers, col-leges and the stakeholders involved in quality of post grad-uate medical education should rely on this availableevidence to build quality frameworks and assessments.The review suggests other pertinent criteria than theundergraduate curriculum to select the candidates for postgraduate medical education. There is a need to define acore curriculum and to combine learning strategies,including simulations and high quality feedback from anauthoritative source. The choice of clinical settings is cru-cial, in particular the opportunity to work in team and tocare for common ailments seen in ambulatory practice.The papers finally provide exhaustive reviews of the avail-able assessment instruments: however they underline theneed for a better assessment of their validity and for anevolution towards a multidimensional assessment.Some gaps in the literature have been identified e.g.

on sub-areas of staffing, training settings, evaluation oftraining process. As an illustration the link between staffperformance and training outcome and the relationshipbetween training and service are hardly addressed inreviews. The selected reviews focus on one or severalparts of the WFME framework but do not take intoaccount their interactions.

Strengths of this systematic reviewThis systematic review was comprehensive, based on themost important indexed databases for medical educationtopics. The selection of papers relied on strict criteriaand the quality of the included papers was furtherassessed [12]. The authors who performed this reviewcame therefore across all challenges mentioned by Reedand colleagues for performing systematic reviews of edu-cational interventions, i.e., finding reports of educationalinterventions, assessing quality of study designs, assessingthe scope of interventions, assessing the evaluation ofinterventions, and synthesizing the results of educationalinterventions [9].

Limitations of this systematic reviewSome limitations inherent to the methodology of this sys-tematic review need to be addressed. An important limita-tion is linked to the choice of key words and searchstrings. The concept of quality covers a broad spectrum:the choice and combination of similar MESH and nonMESH terms was difficult across all databases.A second limitation relates to the authors’ decision to

focus on indexed literature only. Some publicationsfrom the grey literature have been probably missed but

there is a risk to that these lack scientific rigor [1].Another source of incomplete data source might be thedecision to exclude information from reviews thatfocused on one specialty or one technical procedure inmedicine only.A third limitation is the questionable quality of the

primary studies as reported by many authors of the sys-tematic reviews. They noted that most primary studiesrelate to single institutions and that the designs ofincluded studies were often of poor quality. (Rando-mised) controlled trials were seldomly included in thereviews. This means that currently the best evidence inthe reviews on quality in PME relies on descriptive andcohort studies and before-and-after measurements.The classification of papers within the appropriate

areas and sub-areas was a challenge. Some misclassifica-tions might arise from the subjective assessment of theresearchers’ team. In particular, some papers apply tomore than one (sub) area. For instance, the paper ofCarraccio [21] stressed the applicability of portfolios inassessment of trainees (area 3.1), but because of the for-mative applications it could also be placed in trainingcontent (area 2.3), as it represents what trainees do andreflects upon the content of their work. For reasons ofclarity, these three reviews were therefore reported intwo most relevant (sub) areas.The mixed populations in the studies is finally also a

possible limitation to the interpretation of the results.Often other groups than residents were included in thereviews (i.e. medical students, nurses) which makes ithard to identify evidence specific for the group of postgraduate trainees. Educational needs of senior traineesare different from these of junior ones. The heterogene-ity within reviews is of concern and should be identifiedmore precisely by future reviewers.

ConclusionsThis systematic literature review identified and analyzedthe available evidence for some areas of the post gradu-ate training. The majority of the reviews provided infor-mation about the training process, the assessment oftrainees and the trainees. Indicators used for qualityassessment purposes of post graduate training should bebased on this evidence but further research is neededfor some areas in particular to assess the quality of thetraining process.

Key Points of this systematic literature review• This systematic review identified the available goodquality reviews for some areas of the WFME frame-work: training approaches, assessment of trainees andworking conditions are the areas most often reviewed;• Useful criteria to select the candidates for postgraduate medical education exist;


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• There is a need to combine learning strategies:high quality feedback from an authoritative source isa key of success;• A special attention is required for the choice of clini-cal settings: experiences in teams and practice inambulatory care are essential to develop the trainee’scompetences;• Many assessment tools are available but there isneed for a better assessment of their validity and foran evolution towards a multidimensional assessment;• This review identified a gap in reviewed researchfor some (sub) areas of the WFME framework: mis-sion and outcomes, the evaluation of the trainingprocess and the continuous renewal.

Additional material

Additional file 1: Summary of general findings of the selected 31reviews.

AcknowledgementsWe thank Patrice Chalon, librarian of the Federal Knowledge Centre ofHealth Care of Belgium for helping to search the databases.FundingFunding was provided by Belgian Health Care Knowledge Centre. Project2008-27

Author details1Department of Family Medicine, Centre for General Practice, University ofAntwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium. 2Federaal Kenniscentrumvoor de Gezondheidszorg - Centre fédéral d’expertise des soins de santé -Belgian Health Care Knowledge Centre, Kruidtuinlaan 55, 1000 Brussel,Belgium.

Authors’ contributionsAD, RR and DP designed this study. AD, RR and JW selected and analyseddata. AD, RR and JW drafted the manuscript. All authors read and approvedthe final version of the manuscript.

Competing interestsThe authors declare that they have no competing interests.

Received: 10 January 2011 Accepted: 6 October 2011Published: 6 October 2011

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Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/11/80/prepub

doi:10.1186/1472-6920-11-80Cite this article as: Damen et al.: Evidence based post graduate training.A systematic review of reviews based on the WFME quality framework.BMC Medical Education 2011 11:80.

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AbstractBackgroundMethodsResultsConclusions

BackgroundMethodsDatabasesTerms usedSelection procedureQuality appraisal

ResultsPractical messagesWFME areas under studyImportance of a core curriculumConditions to facilitate learning in PME education: combination of learning approachesWork in team: importance of the clinical settingsGrowing importance of the portfolio in post graduate medical trainingSelection and assessment of trainees: shortcomings of the academic resultsAssessment of trainees: a call for a global approachWorking hours and risk of burnout: no optimal answer

DiscussionSome evidence in reviews to build a post graduate training processStrengths of this systematic reviewLimitations of this systematic review

ConclusionsKey Points of this systematic literature review

AcknowledgementsAuthor detailsAuthors' contributionsCompeting interestsReferencesPre-publication history

research article open access evidence based post …a mapping of the best evidence underlying the...

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